Montana Form Hi - Health Insurance For Uninsured Montanans Credit - 2014
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MONTANA
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Clear Form
HI
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2014 Health Insurance
Rev 05 14
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for Uninsured Montanans Credit
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15-30-2367 and 15-31-132, MCA
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Name (as it appears on your Montana tax return)
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100
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Social Security
Federal Employer
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OR
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-
-
-
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X X X X X X X X X
X X X X X X X X X
Number
Identification Number
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Part I. Partners in a Partnership or Shareholders of an S Corporation
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Enter your portion of the health insurance for uninsured Montanans credit here. See
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$_____________________
instructions.
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Business Name of Partnership or S Corporation
Federal Employer
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Identification Number
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___________________________________________________
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Part II. Qualifications
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To qualify for this credit, you must answer yes to all of the four statements below. For the period that I am claiming the credit:
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160
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1. I have been in business in Montana for at least 12 months ..................................................1. Yes
No
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170
2. I employ at least 2 but not more than 20 employees who work at least 20 hours per week ....2. Yes
No
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180
3. I pay at least 50% of each Montana employee’s insurance premium ...................................3. Yes
No
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190
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4. It has been 36 months or less since I first claimed this credit ...............................................4. Yes
No
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Part III. Credit Computation. This tax credit is limited to a maximum of 10 employees.
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Column A
Column B
Column C
Column D
Column E
Column F
Column G
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Enter the
Multiply the
Multiply the
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Enter the
Enter the
Multiply the
percentage
This is your
amount in
amount in
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Employee
employee’s
number of
amount in
of premiums
maximum
Column B
Column
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monthly
months each
Column A by
paid by
monthly
by the
D by the
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premium
employee is
the amount
you as an
credit.
amount in
amount in
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amount.
insured.
in Column E.
employer.
Column C.
Column E.
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200
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250
1.
%
$25
260
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2.
%
$25
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3.
%
$25
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4.
%
$25
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5.
%
$25
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6.
%
$25
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7.
%
$25
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8.
%
$25
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9.
%
$25
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10.
%
$25
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50
270
280
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Total
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290
1. Multiply the total of Column F by 50% (0.50) and enter the result...............................................................1.
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300
2. Enter the total of Column G .........................................................................................................................2.
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310
3. Enter the smaller of line 1 or line 2. This is your health insurance for uninsured Montanans credit ...3.
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Where to Report Your Credit
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► Form 2, Schedule V
► Form CLT-4S, Schedule II
► Form CIT, Schedule C
► Form PR-1, Schedule II
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If you file your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you file electronically, you
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represent that you have retained the required documents in your tax records and will provide them upon the department’s request.
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